First Quarter 2025 HCPCS Updates for Texas Medicaid

Date: April 2, 2025

Attention: Providers

Effective for dates of service on or after April 1, 2025

Call to action: Texas Children’s Health Plan (TCHP) would like to inform you that on March 27, 2025, the Texas Medicaid & Healthcare Partnership (TMHP) implemented the first quarter 2025 Healthcare Common Procedure Coding System (HCPCS) additions, revisions, and discontinuations, which will be effective for dates of service on or after April 1, 2025.

First Quarter 2025 HCPCS Added Procedure Codes

The CAD procedure codes listed in the table above will be added as Medicaid benefits as of the Centers for Medicare & Medicaid Services (CMS) effective date, April 1, 2025. Claims will deny until a rate is implemented, but affected claims will be reprocessed back to the CMS effective date. The procedure codes will be payable at the April 1, 2025, published rate until the Texas Health and Human Services Commission (HHSC) rate hearing is held as required by the Texas Administrative Code 355.201.

Source: https://pfd.hhs.texas.gov/rate-packets

The following procedure code will be added as a Healthy Texas Women (HTW) benefit:

Effective April 1, 2025, the following procedure codes will be added as non-covered procedure codes for Texas Medicaid:

Procedure codes noted with an asterisk in the table above will require a Texas Medicaid rate hearing.

New benefits that are adopted by Texas Medicaid must complete the rate hearing process to receive public comment on proposed Texas Medicaid reimbursement.

Additional Benefit Information
Age limitations will apply for the following procedure codes:

Procedure codes A6515, A6516, A6517, A6518, A6519, and A6611 will each be limited to a quantity of six per year.

Procedure code C9302 will be restricted to diagnosis codes C221, C23, C240, C248, and C249.

Procedure code C9303 will be restricted to the following diagnosis codes:

Quantity limitations and prior authorization Information:

• Procedure code E1022 will be limited to a maximum quantity of two per year, and procedure code E1032 will be limited to a maximum quantity of one per five years.
• Procedure codes E1022, E1032, E1033, and E1034 will require prior authorization.

Refer to the current Texas Medicaid Provider Procedures Manual (TMPPM), Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.17, “Mobility Aids,” for additional information.

• Procedure codes E1832, L0720, L1933, and L1952 will require prior authorization.

Refer to the current Texas Medicaid Provider Procedures Manual (TMPPM), Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.19.2, “Prior Authorization and Documentation Requirements,” for additional information.

• Procedure code J1072 will be a benefit for male clients only and will require prior authorization.
• Procedure code J1072 will not be a benefit when submitted with diagnosis code F640, F641, F642, F648, or F649.
• Procedure code J1299 will be restricted to diagnosis codes D5932, D5939, D595, G360, G7000, and G7001.
• Furosemide (procedure code J1938), when used for the treatment of end-stage renal disease or acute kidney injury, will be included in the composite rate payment and will not be paid separately.

The following procedure codes will require prior authorization:

Refer to the current Texas Medicaid Provider Procedures Manual (TMPPM), Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.20.2, “Prior Authorization and Documentation Requirements,” for additional information.

First Quarter 2025 HCPCS Discontinued Procedure Codes

Effective April 1, 2025, CMS will discontinue the following procedure codes:

Discontinued procedure codes will not be reimbursed after March 31, 2025.

First Quarter 2025 HCPCS Revised Procedure Codes

The description of the following procedure codes will be revised:

First Quarter 2025 HCPCS Informational Procedure Codes

The following procedure codes will be added as informational only:

How this impacts providers: Texas Medicaid managed care organizations (MCOs) like TCHP must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO/TCHP. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should reference a member’s specific MCO/TCHP for information on these items. For TCHP, this information can be found on the provider page available here https://www.texaschildrenshealthplan.org/providers.

Next step for Providers: Providers should share this information with their staff.

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org. 

For access to all provider alerts: https://www.texaschildrenshealthplan.org/providers/provider-news/provider-alerts.